Navigating the “Mental Health Crisis” in Adolescents in the Aftermath of Covid-19 Pandemic: Experience and Insights from Frontline Psychiatric Service

Abstract

The COVID-19 pandemic had a great impact on adolescent mental health, with a dramatic rise in psychiatric emergencies that has challenged healthcare systems worldwide. This paper aims at focusing on reporting the authors’ experience and their data collected on adolescent emergencies in 2022 in Tuscan, within the context of the “Azienda USL Toscana Nord Ovest”, a large department covering about a third of Tuscany’s Regional Health Service, in central Italy. The collected findings will be shortly presented and commented on, while providing insights concerning the importance of adapting healthcare systems to adequately respond to this growing crisis and the need for broader strategies to support adolescent mental health in these challenging times.

The COVID-19 pandemic has brought about an unprecedented and challenging time for individuals worldwide. The pandemic and its associated public health measures have disrupted daily routines, leading to significant changes in the way people live, work, and interact with others. These changes have had a significant impact on the mental health of individuals, particularly adolescents who have been significantly affected. COVID-19, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a viral respiratory illness that first emerged in Wuhan, China in December 2019 (Yong, 2021). The virus rapidly spread to become a global pandemic, with over 245 million confirmed cases and 4.9 million deaths worldwide as of October 2021 (WHO, 2021). The disease primarily spreads through respiratory droplets when an infected person coughs, sneezes, or talks, and the virus can also be transmitted by touching a surface contaminated with the virus and then touching the mouth, nose, or eyes (WHO, 2020). The incubation period of COVID-19 ranges from 2 to 14 days, and symptoms can range from mild to severe, including fever, cough, fatigue, body aches, and shortness of breath (CDC, 2021). Due to its high transmission rate and severity, the COVID-19 pandemic has caused significant global health, social, and economic impacts. It has overwhelmed healthcare systems, leading to shortages of personal protective equipment, hospital beds, and medical personnel (Marazziti and Stahl, 2020; Panda et al., 2021). The pandemic has also resulted in significant social and economic impacts, including widespread job losses, business closures, and disruptions to education and travel (Marazziti et al., 2021; Nicola et al., 2020). The global scientific community has made tremendous efforts to better understand and manage the COVID-19 pandemic, from developing effective vaccines to implementing public health interventions such as social distancing and mask-wearing (Gostin & Wiley, 2020). However, challenges still remain in the fight against the pandemic, such as vaccine hesitancy, misinformation, and the emergence of new variants (Mallapaty, 2021).

The purpose of this commentary is to shed light on the profound impact that the COVID-19 pandemic has had on mental health, with a specific focus on a particularly vulnerable demographic — children and adolescents. While the mental health implications of the pandemic are universal, it has become increasingly clear that young people are at an elevated risk, due to the significant disruptions to their education, social life, and routines. Within this context, our discussion is narrowed down to a specific geographic area within the National Health Service (NHS) of central Italy — the Azienda USL Toscana Nord Ovest (ATNO). This region provides a case study of the challenges faced by healthcare providers in managing the rising tide of psychiatric emergencies among children and adolescents in the era of COVID-19. The commentary aims to provide a detailed analysis of the situation in the ATNO region, highlighting the strain on the emergency departments (EDs), the subsequent "funnel effect" in patient transfers to specialized psychiatric facilities, and the need for comprehensive care pathways post-ED visit. The goal is to stimulate a broader discussion about the necessary measures to address the mental health crisis among young people, to inform policy and healthcare strategies, and ultimately, to improve the mental health outcomes for this vulnerable population in the post-pandemic world.

COVID-19 and mental health: three years challenge

The COVID-19 pandemic has not only had a significant impact on physical health, but also on mental health. The outbreak and subsequent measures to control its spread have caused widespread psychological distress, particularly among vulnerable populations such as healthcare workers, older adults, and individuals with pre-existing mental health conditions (Kozloff et al., 2020; C. Wang et al., 2020). The pandemic has disrupted daily life, leading to increased social isolation, economic uncertainty, and fear of infection, which have all contributed to the deterioration of mental health (Xiong et al., 2020).

Studies have reported an increase in mental health problems, including anxiety, depression, and stress, among individuals during the COVID-19 pandemic (Bao et al., 2020; Diolaiuti et al., 2021; Dubey et al., 2020; Orrù et al., 2021). The pandemic has also resulted in an increase in the use of mental health services, including telepsychiatry and online therapy, as individuals seek support for their mental health concerns (Torales et al., 2020).

Furthermore, the pandemic has had a significant impact on the mental health of frontline healthcare workers, who have experienced high levels of stress and anxiety due to the risk of infection, long working hours, and shortage of personal protective equipment (PPE) (Kang et al., 2020; Marazziti, 2020; Mucci et al., 2020; Shanafelt et al., 2020). The mental health of children and adolescents has also been affected by the pandemic, with reports of increased stress and anxiety, disrupted education, and reduced access to mental health services (Meherali et al., 2021; Lee, 2020).

Overall, the COVID-19 pandemic has had a significant impact on mental health, affecting individuals of all ages and demographics. The need for effective mental health interventions and support is critical to addressing the mental health consequences of the pandemic.

COVID-19 and mental health in children and adolescents: the true scourge of a fragile humanity

Different data show that adolescents resulted to be one of the most vulnerable populations hit by COVID-19 pandemic in terms of s mental health consequences (Jones et al., 2021). Adolescents lack the psychological capabilities of resilience and coping and the physiological development of adults that makes their mental health challenges during the pandemic even greater (Jones et al., 2021). Studies found that stressors and motivations to practice social distancing due to the COVID-19 pandemic are difficult for adolescents to process, leading to poor mental health outcomes (Jones et al., 2021). Negative coping skills, such as addiction to smartphones and the internet, also contribute to depression, stress, and trauma among various ages of adolescents (Jones et al., 2021). Therefore, it is crucial to provide adolescents with positive coping skills to improve their mental health outcomes during periods of adjustments (Jones et al., 2021; Meherali et al., 2021; Mukhtar, 2020; Pfefferbaum & North, 2020).

In addition, social support is crucial for mental sustainability among adolescents during periods of crisis, such as the pandemic. Adolescents with perceived low to moderate social support during the pandemic had increased rates of anxiety and depression (Jones et al., 2021; Orgilés et al., 2021; Meherali et al., 2021, Oosterhoff et al., 2020; Viner et al., 2020). Adolescents also face unique challenges during the pandemic, such as dealing with unsupportive families due to sexual orientation, with the lack of social and medical support for various pre-pandemic disorders, and dealing with new and old stress from previous traumas (Jones et al., 2021).

Although a lot of studies also showed a consistent link between the pandemic and mental health, especially in adults (C. Wang et al., 2020; Huang and Zhao, 2020; Pappa et al., 2020), however, only a few studies have evaluated the impact of the pandemic on mental health in adolescents. Some studies found no significant changes in depression, anxiety, and stress in Chinese adolescents over time (G. Wang et al., 2020). Other authors reported high levels of depression and anxiety in another group of Chinese adolescents during the peak of the pandemic, although lower levels were reported among males and youth that regularly engaged in exercise (Chen et al., 2020). In Canada, adolescents and young adults perceived reductions in their mental health across the pandemic period, particularly in depression/low mood and anxiety (Hawke et al., 2020). Adolescents were most concerned about the impact on their schooling, followed by general concerns about the COVID-19 crisis, and not feeling connected to friends (Ellis, Dumas, & Forbes, 2020). COVID-19 related concerns were positively associated with depression and loneliness, while spending more time with family and friends, and engaging in more physical activity, were negatively associated with depression and loneliness (Ellis, Dumas, & Forbes, 2020).

The COVID-19 pandemic also caused stress, worry, helplessness, and social and risky behavioural problems among children and adolescents, including substance abuse, suicide, relationship problems, academic issues, and absenteeism from work (Meherali et al., 2021; UNICEF, 2020). Effective mental health strategies tailored to children's and adolescents' needs, such as art-based programs, support services, and clinician-led mental health and psychosocial services, are necessary to improve their mental health outcomes during pandemics (Meherali et al., 2021; Pfefferbaum & North, 2020; Ren et al., 2020). As the pandemic resolves, it remains crucial to monitor its future impact on children's and adolescents' mental health status and provide them with the necessary support to improve their mental health outcomes (Meherali et al., 2021; UNICEF, 2020).

The Northwest Tuscany Local Health Authority (ASL Nordovest Toscana) maintains a network of Functional Mental Health Units for Children and Adolescents (UFSMIA) throughout its designated territorial districts. However, these units do not specifically cater to the inpatient treatment of emergent child psychopathology; rather, they focus on outpatient services, providing psychiatric and psychological specialist support, along with social assistance. Dedicated inpatient units for children experiencing neuropsychiatric disturbances are limited to two facilities: AOU Meyer and IRCCS Stella Maris. These facilities, however, possess a somewhat limited number of available beds. Therefore, a protocol has been developed to address emergencies and delineate the potential pathway to hospitalization (Azienda USL Toscana Nord Ovest, 2019).

COVID-19 and mental health in children and adolescents: a closer look to North-West Tuscany

Psychiatric emergencies involving children and adolescents invariably start with the patient’s admission to the emergency department (ED), then a pediatrician or psychiatrist is engaged, depending on the age of the patient (cut-off at 16 years). During the operational hours of the UFSMIA, a child neuropsychiatric (NPI) consultation is sought within the ED. Should hospitalization be deemed necessary, an immediate transfer request is made subject to the availability of beds specifically allocated for child psychiatric emergencies at the AOU Meyer and IRCCS Stella Maris facilities. In the event of no available beds, the patient is admitted to the local hospital's Psychiatric Diagnosis and Care Service (SPDC) (for patients over 16 years) or the Pediatrics Department (for patients under 16 years). For patients between the ages of 14 and 16, SPDC admission may be considered in instances of severe self-harm, significant psychomotor agitation, etc., though never for those under 14 years of age, who are invariably admitted to the Pediatrics Department. In the case of patients requiring hospitalization, the UFSMIA provides daily neuropsychiatric consultations while awaiting transfer and for the duration deemed necessary. This involves sharing the therapeutic journey in both the SPDC and Pediatrics Departments, alongside a reconfiguration of the planned outpatient activities (i.e., rescheduling of outpatient appointments, limiting the scheduling of visits based on availability dedicated to emergencies). During the non-operational hours of the UFSMIA, if urgent circumstances arise, the psychiatrist of the Diagnosis and Care Service provides consultation for preadolescent/adolescent patients hospitalized in Pediatrics, if requested. The initial critical phase can evolve in different ways:

• The patient is discharged from the hospital and taken into outpatient care by the UFSMIA service. In this case, the patient is discharged with a scheduled appointment date.

• The patient is discharged from the hospital, taken into outpatient care by the UFSMIA service, and concurrently admitted for day hospital treatment at IRCSS Stella Maris.

• The patient is discharged from the hospital and transferred to IRCSS Stella Maris Scientific Institute / AOU Meyer Hospital for inpatient care.

• The patient is discharged from the hospital and transferred to a Therapeutic Community.

The patient transfer from the local hospital to the IRCSS Stella Maris Scientific Institute / AOU Meyer Hospital (or so-called "third level") occurs according to the procedures established in the Hospital/District Zone for patient transfer from one hospital facility to another. The discharge from the third level pathway involves the territorial UFSMIA team agreement on the following procedures:

• territorial takeover and/or inclusion in a semi-residential centre for adolescents and/or

• a day hospital at IRCSS Stella Maris Scientific Institute / AOU Meyer Hospital

• and/or admission into a residential therapeutic-rehabilitative structure)

• and a follow-up in UFSMIA visit within 7 days of discharge.

The outlined protocol, as it stands, was released in 2019, and at that time, it adequately fulfilled the needs of the system with only minor issues arising. It was designed to provide a structured approach for addressing child and adolescent psychiatric emergencies within the jurisdictions of the Northwest Tuscany Local Health Authority (ASL Nordovest Toscana). However, over the last three years, there has been a substantial escalation in the number of psychiatric emergencies involving adolescents. This upsurge has inevitably placed additional pressures on the pre-existing infrastructure and resources, perhaps revealing limitations in the initial protocol and posing questions about its current capacity to meet the amplified demands. Regrettably, a comprehensive comparison with the preceding years is not possible, as data from those periods are unavailable. Nonetheless, we still have the capacity to comment on the pattern of admissions to the ED over the course of the 2022 period. This analysis will offer valuable insights into the nature and extent of the recent increase in psychiatric emergencies among minors, and potentially guide the re-evaluation and adjustment of the protocol to better suit the current needs.

Analyzing the 2022 data of the different areas, the following trends were observed:

• Elba Island: There were a total of 2 cases of self-harm/suicidal tendencies and 1 case of eating disorders (DCA), associated with cannabinoid use. The age of patients admitted ranges from 12 to 18, with 5 cases in the 14-18 age group. Gender data were not provided.

• Valli Etrusche: a total of 5 cases of self-harm/ suicidal tendencies and 1 case of eating disorders. All patients fall within the 14-18 age range. Gender data is not available.

• Valdera - Alta Val di Cecina: While specific data regarding the nature of the cases and the demographics of the patients are not provided, we do know that there was a total of 11 admissions in 2022.

• Livorno reports 6 cases of self-harm/suicidal tendencies, 9 cases of agitation, and 4 cases of eating disorders. The age distribution shows 2 cases below 12 years old, 2 cases between 12-14 years, and 12 cases of individuals between 14-18 years of age. The gender distribution shows a slight female predominance, with 9 females and 7 males.

• Pisa reports 6 cases of self-harm/suicidal tendencies, 10 cases of agitation, and 6 cases of eating disorders. The age distribution shows 6 cases in the 12-14 age group and 16 cases in the 14-18 age group. The gender distribution shows a female predominance, with 15 females and 7 males.

• Versilia reports 10 cases of self-harm/suicidal tendencies, 8 cases of agitation, and 14 cases of eating disorders. There were also 7 other cases, including 1 direct request. The age distribution shows 2 cases below 12 years old, 10 cases in the 12-14 age, and 27 cases in the 14-18 age group (including 2 direct requests). The gender distribution shows a significant female predominance, with 37 females and 2 males.

• Lucca reports 21 cases of self-harm/suicidal tendencies, 5 cases of agitation, and 4 cases of eating disorders. The age distribution shows 1 case in the 12-14 age group and 29 cases in the 14-18 years group. The gender distribution shows a nearly balanced ratio, with 19 females and 11 males.

• Valle del Serchio reports 1 case of self-harm/ suicidal tendencies and 1 case of eating disorders. Gender and age distribution was 1:1.

• Lunigiana reports 1 case of self-harm/suicidal tendencies, 1 case of agitation, and 3 cases of eating disorders. All patients are female, and the age distribution shows 3 cases at 14 years old and 2 cases at 17 years old.

• Apuane reports 12 cases of self-harm/suicidal tendencies, 10 cases of agitation, and 11 cases of eating disorders. The age distribution shows 3 cases below 12 years old, 11 cases in the range 12-14, and 30 cases in the group from 14 to 18 years. The gender distribution shows a female predominance, with 31 females and 13 males.

Considering these statistics, the total number of pediatric ED admissions for psychiatric reasons in the region of Azienda USL Toscana Nordovest (ATNO) in 2022 was 193. When considering the 52 weeks in a year, this translates to an average of approximately 3.7 urgent psychiatric admissions per week involving minors. (table 1)

Table 1.

Emergency report in Azienda USL Toscana Nord Ovest (ATNO) 2022

YEAR 2022 Energency Admissions	PEDIATRIAC WARD(s)	ADULT PSYCHIATRY WARD(s) (SPDC)	AUO MEYER	IRCCS STELLA MARIS	DIAGNOSI a) Suicidality b) Agitation c) Eating Disorders (EDs) d) other	M:F	AGE (<12 12-14 14-18)	TOTAL EMERGENCIES ATNO
Elba	1	1	1	2	a-b) 2 c) 1	n/a	12<14 =1 14<18= 5	5
Valli Etrusche	3	1	1	6	a) 5 c) 1	n/a	14-18	7
Valdera-AVCecina	n/a	n/a	n/a	n/a	n/a	n/a	n/a	11
Livorno	10	7	2 DCA	9	a) 6 b) 9 c) 4	7: 9	<12: 2 12-14: 2 14-18: 12	28
Pisa	4	2	0	16	a) 6 b) 10 c) 6	7:15	12-14: 6 14-18:16	22
Versilia	26	11	0	8	a) 10 b) 8 c) 14 d) 7	2:37	<12: 2 12-14: 10 14-18: 27	39
Lucca	18	12	0	20	a) 21 b) 5 c) 4	11:19	12-14: 1 14-18: 29	30
Valle del Serchio	1	1	4		a) TS 1 c)DCA 1	1:1		2
Lunigiana	3	2			a) 1 b) 1 c) 3	1:5	14: 3 17: 2	5
Apuane	25	19	1	3	a) 12 b) 10 c) 11	13:31	<12: 3 12-14:11 14-18:30	44
Total	91	56	9	64	-	-	-	193

Discussion

Out of the total of 193 emergency admissions in 2022, 91 were recorded in Pediatrics departments and 56 in the Psychiatric Diagnosis and Treatment Services (SPDC). Technically, however, these departments are not ideally equipped to handle such cases on a long-term basis. Pediatrics departments, while admitting those under 16, and SPDC, admitting those over 16, are meant to provide only temporary care for such mental health cases.

The total number of 193 initial ED visits by minors for psychiatric issues in the Azienda USL Toscana Nordovest (ATNO) region in 2022 stands in stark contrast to the 73 transfers to specialized facilities (IRCSS Stella Maris and AOU Meyer). This discrepancy highlights what could be described as a "funnel effect," with a significant number of initial ED visits, but a significantly smaller number of transfers to specialized psychiatric facilities. This "funnel effect" represents a key concern for the ATNO, implying a capacity issue at the level of specialized psychiatric care for minors, with only a fraction of those initially seen in the ED eventually being transferred to a more specialized centre. The disparity between the number of initial ED visits and the number of transfers also raises questions about the care pathways for these children and adolescents after their initial assessment. If a significant number of them are not being transferred to specialized care, it remains crucial to adequately address those young people for follow-up care. This situation calls for further analysis to identify potential bottlenecks in the system and to develop strategies to ensure that all young people presenting with psychiatric emergencies receive the appropriate level of care. Addressing the "funnel effect" may involve expanding the capacity of specialized facilities, developing additional care pathways for those who are not transferred, or strengthening preventative and early intervention services to reduce the demand for emergency psychiatric care.

The diagnoses associated with these admissions include suicide attempts/self-harm, afternoon agitation, and eating disorders. Each of these indicates severe mental health concerns, further emphasizing the need for specialized care and resources. The geographical distribution of cases highlights areas of particular concern, with the highest number of cases reported in Versilia (39 cases), Lucca (30 cases), and Apuane (44 cases). This underscores the need for targeted resources and improved services in these areas. An analysis of the gender distribution reveals stark disparities. The data indicates that girls are significantly more likely to be admitted than boys. In almost all areas, there is a higher ratio of female to male admissions, with Versilia demonstrating the most pronounced disparity with a ratio of 37:2. This suggests that girls may be more vulnerable to mental health crises or more likely to seek help. Again, the overall female sex is more prone to the psychopathological disturbances reported in our samples. However, it is important to consider other potential factors such as societal and cultural norms that may affect the likelihood of boys seeking help for mental health issues. The age distribution provides additional insights. Across all locations, the group between 14-18 years represents the majority of cases. In particular, Lucca and Apuane areas reported the highest number of cases in this age group with 29 and 30 cases, respectively. This suggests that older adolescents are particularly vulnerable to mental health crises. However, it is important to note that there are also cases in the younger age groups (<12 and 12-14), indicating that mental health issues can affect children and adolescents of all ages. The number of cases in the younger age groups might be underestimated due to barriers in recognizing and diagnosing mental health issues in younger children. These findings highlight the need for targeted mental health interventions and resources that are sensitive to gender and age-specific requirements, as well as for further research to understand the factors contributing to these gender and age trends.

Future perspectives and conclusions

In light of the numbers of adolescence emergencies reported herein, a vital area of intervention is undoubtedly the strengthening of health care resources. As a case in point, the Tuscany region in Italy currently faces a severe lack of child and adolescent neuropsychiatry departments, with only two such departments for the entire population (namely the IRCSS Stella Maris and the pediatric hospital Meyer). At the present time, this number is starkly inadequate to meet the growing mental health needs of this demographic and to address this 'epidemic within the epidemic' that we are currently witnessing. Therefore, it is of the utmost importance that significant resources are allocated to create small hospital wards dedicated to childhood and adolescence mental health within the different territorial hospital facilities in Tuscany, not to mention investing in the recruitment of neuro-psychiatrists and psychologists. Furthermore, the training of educators, nurses, and auxiliary staff to manage such situations is paramount. This underlines the need for political intervention, in agreement with the National Health Service and schools, to prioritize and address these pressing issues. These actions are imperative if we are to mitigate the devastating impact of the pandemic on the mental health of our younger generations.

One important strategy is the provision of social support. Adolescents who perceive low to moderate social support during the pandemic are at increased risk of experiencing anxiety and depression (G. Wang et al., 2020; Jones et al., 2021). Therefore, it is important to provide adolescents with social support through different means, such as connecting with friends and family virtually, participating in support groups, and accessing mental health services.

Schools and educators, being at the forefront of child and adolescent development, play a critical role in providing social support and teaching positive coping skills. In the face of the pandemic's mental health impact, schools should be seen as more than just educational institutions, but as vital agents in promoting the wellbeing of their students. This could involve implementing school-wide mental health programs to foster a supportive environment and increase awareness of mental health issues among students. Teachers should also receive training to recognize signs of mental distress in their students and know how to guide them toward appropriate resources. The incorporation of mental health education into the curriculum can equip students with knowledge about mental health, reducing stigma, and promoting help-seeking behaviour. Additionally, schools can facilitate access to mental health services by employing school psychologists or providing referrals to external services. Furthermore, as social distancing and remote learning continue to disrupt traditional school activities, educators and school administrators should explore innovative ways to maintain social connections among students, such as through virtual gatherings or mentorship programs.

Another strategy is the implementation of positive coping skills. Adolescents who engage in negative coping behaviours, such as addiction to technology and substance abuse, are at increased risk of experiencing depression, stress, and trauma during the pandemic (Huang, Y., & Zhao, N. (2020; Jones et al., 2021). Effective mental health strategies tailored to adolescents' needs, such as art-based programs, support services, and clinician-led mental health and psychosocial services, can help to improve their mental health outcomes during pandemics (Meherali et al., 2021; Pappa et al., 2020).

By promoting social support and positive coping skills, it seems possible to mitigate the negative impact of the COVID-19 pandemic on adolescent mental health. However, it is important to continue monitoring the mental health status of adolescents during and after the pandemic to ensure that appropriate support and resources are available. While provision of social support and positive coping skills are fundamental, it is equally crucial to ensure access to appropriate mental health resources. In Tuscany, and indeed throughout Italy, the demand for mental health services has dramatically increased during the pandemic, and the current infrastructure struggles to meet these needs. At present, there is a severe deficit of hospital beds for child and adolescent neuropsychiatry departments in Tuscany. The limited resources that exist are stretched thin, often leaving young people without the necessary access to mental health care. Therefore, it is imperative to significantly invest in the expansion and enhancement of mental health services. This could involve increasing the number of hospital beds dedicated to child and adolescent mental health, employing more specialized mental health professionals, and developing comprehensive outpatient services to provide ongoing support for young people. In addition, it is essential to ensure that mental health services are accessible to all who need them. This may require investing in mobile health units or telemedicine services to reach those in rural or underserved areas. On a policy level, healthcare planners and decision-makers need to prioritize mental health in their agendas. This includes allocating sufficient funding to mental health services, integrating mental health care into primary health care settings, and collaborating with educational institutions to provide mental health support to students. While these are substantial challenges, addressing them is essential for the well-being of our younger generations. The COVID-19 pandemic has exposed significant gaps in our mental health care system, and it is our collective responsibility to address these issues and ensure that all young people have access to the care they need.